Managing the Contaminated Airway

By: Benjamin Fedeles, MD

"By failing to prepare, you're preparing to fail." – Benjamin Franklin

You look down at your pager once again as you bound up the stairs, two at a time, double checking that the code is indeed on the medicine floor. As you exit the stairwell, you try and slow your breath, collect your thoughts, and prepare as best as you possibly can for the scene that you are about to walk in to. You raise your voice slightly, trying to part the sea of people – nurses, techs, students, Residents, and finally make your way to the scene and identify yourself to the rest of the Code Team that responded. A middle-aged woman is laying supine on the floor, lower body halfway through the threshold to the patient bathroom, upper torso in the hallway with barely two feet between her head and the wall. Her hospital gown and the telemetry leads, tucked into her gown’s pocket, are covered in vibrant maroon blood which continues to intermittently spew from her mouth between the agonal gasps, the gaggle of providers around her only slightly shielded by the respiratory therapist’s bag valve-mask, as they work to secure working IV access and apply monitors.

This was the scene from a rapid response that I responded to as a Chief Resident, which quickly deteriorated into a code, driven by the patients hemorrhagic shock from an upper GI bleed, acute on chronic anemia, and the inability for her to protect her airway, ultimately resulting in an hypoxic arrest complicated by aspiration. Not that any code is ideal, this one was less than ideal for several reasons: the physical space, the environment, the resources, and most importantly, patient factors.

I will focus this discussion on how I manage a soiled or contaminated airway, including pearls and pitfalls. Secretions, vomitus, or frank blood are all offenders, and can occur in up to 20-30% of out of hospital cardiac arrests (1). Even with high quality chest compressions, the inability to adequately ventilate or oxygenate patients has an impact on morbidity and mortality. The mainstay approach I utilize in this is called the “SALAD” technique, as described by Dr. Ducanto (2), which stands for Suction-Assisted Laryngoscopy Assisted Decontamination. The key to this technique is adequate and robust suction – without it, it is practically a blind technique. If possible, have a second suction device set up and ready to go, or at least a second canister. Task someone specifically with setting up suction, rather than providing a generalized statement of “I need suction,” or the bystander effect is at risk of sabotaging your request. Additionally, having the patient positioned adequately, at or near the airway operator’s xiphoid process, is extremely helpful, but often times impossible, especially in emergency situations. Do you best to optimize your position, if you can’t optimize the patient’s. Lastly, be sure to wear appropriate eye protection!

The goal of the SALAD technique is to decontaminate and clear the view of your airway as you go, in a step-wise fashion. The actual SALAD is as follows:

1. Insert the yankauer or rigid suction catheter into the mouth and sequentially decontaminate, moving distally while using the suction as a tongue blade, depressing the tongue prior to inserting your laryngoscope

2. Insert laryngoscope, doing your best to avoid contaminating your optics and light source, while advancing suction to hypopharynx and navigating posteriorly towards esophagus

3. Identify your airway landmarks sequentially and once your glottic opening view is optimized, translocate the suction to the left side of the patient’s mouth, securing it in place with the blade of the laryngoscope and ensure that any ongoing emesis or bleeding is decompressed by the suction

4. Ensure you have adequate tongue sweep and upward translocation of the jaw, to create a channel for the bougie or endotracheal tube to pass easily

5. Intubate the trachea under visualization, secure, and verify placement

Of course, like any technique, it requires practice to understand the song and dance of the movements and steps. The first time you perform a SALAD should not be in real life – work to practice the steps in a mannikin, or even in a controlled setting when not clinically indicated. In addition, this technique only works if you have an adequate view of the airway. From my experience, there is often a high likelihood of vomit or blood contaminating the optics of your video laryngoscope, either from the inability of suction to keep up with output, malposition of suction, or failure to decontaminate the airway sequentially before step wise advancement of your laryngoscopy blade. Anticipating this possibility is paramount, and having a plan in place, whether it is additional suction, blind intubation using a bougie or light-wand, or moving to a surgical airway early, is paramount. Using the IntuBlade video laryngoscope can attenuate these potentially catastrophic failures by providing the airway operator the ability to clear contamination from the video screen, saving time and increasing the first past success rate.

In summary, in a contaminated airway:

• Identify someone to set up suction before proceeding, and ideally have a second suction available for redundancy

• Be sure to wear eye protection

• If clinically indicated, provide a careful and thoughtful rapid-sequence induction

• SALAD

• Secure, suction airway if possible using a suction catheter, verify placement

• Continue supportive care and address the underlying cause, provide sedation if indicated, and consider early bronchoscopy

• Anticipate the sequelae of aspiration pneumonitis

Preparation favors the prepared. The SALAD technique is a well described and utilized approach to the contaminated airway. The addition of an IntuBlade video laryngoscope to this technique further enhances the chances of first pass success and decrease the need for potential additional attempts or failure.

References:

1. Simons R. W. Rea T. D. Becker L. J. & Eisenberg M. S. (2007). The incidence and significance of emesis associated with out-of-hospital cardiac arrest. Resuscitation, 74, 427–431. PubMed

2. Ducanto J, Serrano KD, Thompson RJ. Novel Airway Training Tool that Simulates Vomiting: Suction-Assisted Laryngoscopy Assisted Decontamination (SALAD) System. West J Emerg Med. 2017;18(1):117-120. DOI: 10.5811/westjem.2016.9.30891 . https://youtu.be/Jaq-vHbcGi0?si=B9eWDDO5FmFoOyHU&t=21

Major Ben Fedeles M.D., USAF MC is an Anesthesiologist and Intensivist, practicing at the University of Cincinnati Medical Center, where he is stationed as part of the Center for Sustainment and Trauma Readiness Skills (CSTARS) – Cincinnati. He is Cadre for the Critical Care Air Transport Team (CCATT) Advanced Course.

The Department of Defense does not necessarily endorse, support, sanction, encourage, verify or agree with the comments, opinions, or statements contained therein